By Carolyn Roe, MSM, BSN
The following scenario depicts troubled relationships in a multiunion healthcare system—and describes how frontline nurse managers positively affected the situation.
In the first scenario in the May 2009 issue of The Business of Caring, I showed how a nonunionized healthcare organization successfully resolved volatile staffing and patient care issues. The resolutions presented in that article also have implications for leaders managing a unionized workforce.
- Walk in the shoes of staff.
- Hold one-on-one staff conferences to diagnose the cause of significant deviations in desired outcomes. Ask staff: What is one thing management can do to improve care?
- Take actions to remove barriers that are impeding professional practice, including implementing disciplinary actions and reward and recognition programs.
- Address the biggest issue that staff feel they are facing, and empower staff to help resolve the concern.
- Refuse to get caught up in negativity, teach staff how to manage gossip, and how to address peers when conflicts arrive.
- Be a role model and advocate for staff. Involve the medical staff and other departments in addressing interdepartmental concerns that are negatively impacting service.
Frontline managers will have a harder time affecting change and achieving desired outcomes in the unionized setting. According to research and experience, Ricardo Torres, CEO of Permanent Solutions Labor Consultants, states that the unionized organization will potentially lag behind the nonunion competitor in profits by at least 30 percent over a 10-year period. This is the result of the combined effects of the union compensation premium and the negative impact on productivity and organizational growth. My experience as a leader in unionized healthcare organizations supports PSLC’s position that profits are harder to come by as the percentage of unionized employees increase.
With this in mind, the right managers can be effective in minimizing the effects of unionization and in achieving desired outcomes. This second real-life scenario will show you additional strategies to use when RNs and support staff are represented by unions, typically different unions.
The Situation
A respected healthcare system with three different unions had experienced several devastating patient outcomes that involved multimillion dollar lawsuits. The common denominators in each of these: poor communication between caregivers and a lack of professional accountability.
Inexperienced nurse leaders had been scared to take necessary disciplinary actions against the staff involved in these cases because of possible union ramifications and threats by the staff to “go to the union.” This occurred at the same time there was a change in the CNO. The new CNO was a bright but unseasoned nurse with no previous senior leadership experience. She, too, was worried about union repercussions and was reluctant to take necessary actions for patient safety. As illustrated in the next section, these fears were unwarranted.
Fortunately, two savvy nurse leaders—the risk manager and the hospital’s patient care manager who had experience in labor environments—teamed up to achieve a turnaround in less than five months.
Many of the resolutions they came up with involved correcting misconceptions about unions and building bridges with union representatives.
The Resolutions
Walking into the above scenario could be a life-changing event and isn’t recommended for the faint at heart. Neither of these two leaders was afraid of jumping in with both feet. They followed the steps outlined at the beginning of this article to uncover and resolve the underlying problems. What did they find? What did they correct immediately and how?
Correct misconceptions that unions must be consulted prior to taking necessary precautions to protect patients. The nursing staff was a highly qualified workforce that took continuing education very seriously. Seventy-five percent of the staff had BSNs, and several had MS degrees. However, what the nursing staff did not take seriously was holding themselves and their peers accountable for professional practice.
For example, shortly after the hospital’s patient care manager and the risk manager began their quest to right the wrongs, an experienced ICU nurse put a patient at risk by inappropriately applying restraints. What was even more discouraging was the nurse had gotten buy-in from her peers before applying the restraints in an attempt to manage a disruptive patient. After the two managers consulted, the patient care manager met with the ICU nurse who agreed that she had not followed policy and that the patient could have died. She was very upset with herself and accepted a suspension while a full investigation occurred. She was also given an assignment to research alternative actions that she could have taken rather than disregarding patient safety.
Within minutes of the nurse’s suspension, the CNO called the patient care manager irate that the union wasn’t consulted prior to the suspension. She was certain that the organization would be “in trouble” with the union. Nothing could have been further from the truth. The need to consult with unions on patient safety issues prior to taking corrective action is a myth held by many nurse leaders—and can prevent them from taking necessary actions.
In actuality, when the patient care manager contacted the local union authority, who was a MS-prepared RN, he commended her management of the incident. He was very concerned that the other nurses did not recognize their accountability to protect patients and would stand by and watch poor practice and not intervene. As a result, the union provided mandatory in-service for members on accountability and peer responsibilities.
Provide education on union contract terms. The terms of the different union contracts were not well known by staff or leadership at the health system. As a result, leaders and staff took actions inconsistent with contract provisions, negatively impacting communications and patient care. I could fill up this article with examples. Instead, I will say that the patient care manager and the risk manager joined forces to provide around-the-clock staff education.
The patient care manager educated staff on union contract language, and the responsibility of each staff member to appropriately exercise the chain of command when issues arise that can negatively impact care. In addition, the risk manager held small, group sessions on the importance of communication, particularly when handing off patient care responsibilities and informing physicians of significant changes in patient conditions. The patient care and risk managers role modeled appropriate language and recommendations. Staff meetings focused on quality and performance improvement, and staff became active participants in improving patient outcomes.
Avoid blaming union contracts. The medical staff was skilled and practiced a multidisciplinary approach but felt the union made the environment very frustrating for patients and medical staff. There was some basis for their beliefs. Nursing administration and hospital authorities had agreed to some contractual language in union agreements about staffing, breaks, vacation, and policy enforcement that were not in the best interest of patient care or all staff. These terms also made appropriate staffing difficult.
However, staff tended to respond to patient and physician questions by “blaming” the union or administration. To change this dynamic, the managers taught employees how to work within the terms of the union contracts, plan better, and give needed care without verbalizing blame and pointing fingers.
The patient care manager also implemented four-hour shifts that helped cover breaks and peaks in workload. This was embraced by staff throughout the hospital, the union, and physicians. To everyone’s surprise, these shifts were cost effective and boosted morale among staff.
Encourage union liaisons to improve their clinical skills/performance. Some of the most active union leaders at this health system were not the most competent nor skilled nurses, and they promoted union interests that were not always in the best interest of patients. This was a real challenge for the two managers because the union contract wasn’t due for renewal for two more years.
The managers had two choices: make the union leaders better nurses or neutralize their influence. In actuality, the two managers ended up achieving both goals.
One union liaison had been a superb nurse but, as her union involvement increased, her clinical interests and skills had decreased. The patient care manager implemented peer reviews for this nurse in concert with performance reviews. Through this process, this nurse/union liaison sought mentoring and coaching and brought her skills up to her previous high level of performance—and she returned to being a strong patient advocate.
The other union leader did not take advantage of the peer feedback and did not grow in her skills. As a result, the staff quit going to her for assistance or opinion. When she made clinical errors, her peers supported management because they were tired of this union liaison pulling the team down and contributing to poor patient satisfaction scores. As the liaison’s power and influence decreased, she became disenchanted and moved on to another facility.
Involve staff in improving care and patient satisfaction. Patient satisfaction had remained below health system standards for the previous two quarters. As a result, the administration developed an “I have time” motto as an effort to increase scores. Staff were asked to wear buttons that said “I have time.” The goal was to correct patients’ perception that staff members were too busy to answer questions or even communicate caringly to patients and families. The staff had not been involved in designing this system and rebelled at the idea of one more thing to do. Again, the union was used as a reason not to comply, and nurses complained that “this wasn’t listed as a required duty.”
Both the risk and patient care managers took on the task of implementing the “I have time” motto. They involved staff in redesigning strategies and role modeling responses that would make time for patients, save nurses time, and win the appreciation of their patients. For example, a new approach to answering patient call lights and family phone calls was implemented. Staff members were taught to quit putting patients and families on hold without asking permission and to limit hold time to one minute. If the intended receiver could not come to the phone or meet the request immediately, staff would take a message with a promise to call back in a reasonable time. A special notepad was designed to include who called, who took the message, phone number, concern, and time promised for a return call. The notes were placed on the appropriate staff member’s clipboard. Staff were amazed that this simple strategy could give such great dividends.
In one quarter, patient satisfaction rose by 5 percent, and staff embarked on additional measures to raise scores above the system standard. Significant untoward events decreased and event reporting increased, raising quality as well as patient satisfaction.
Additional Strategies
Frontline managers can make immediate positive impacts on patient care in a unionized facility. Here are some additional resolutions to try:
- Clarify and document the issues and be sure of your facts. Have a witness to discussions with employees about unsatisfactory work performance. Apprise an employee of his rights to have union representation in a conference, if disciplinary action is anticipated.
- If union negotiations are imminent, make sure staff and negotiators understand the ramifications of some contract provisions that drive up costs and negatively impact patient care. Again, deal in facts not “pet peeves,” and dispel myths about administration and the union.
- If staff verbalizes unhappiness with their labor union, listen and refrain from verbalizing your opinion. Do refer them on to a resource that can assist them in resolving their concern.
- Do not be bullied into tolerating poor care to “keep peace” with the union. Instead, solicit the cooperation of union officials, and build bridges not barriers.
- Ignite staff in activity that focuses on improving patient care and the work environment, continuing to stress the question, “What is best for the patient?”
- Communicate any observations of unfair labor practices by the hospital or the union to the appointed administrative representative, as soon as possible.
Carolyn Roe, MSM, BSN, is currently associated with Permanent Solutions Labor Consultants; her background includes positions as chief nurse executive, vice president, and interim leader within various health systems (info@pslabor.com).
Additional Resources
Read Carolyn Roe's advice for influencing positive labor relations in a nonunion environment.